Credentialing and Re-Credentialing Requirements

The credentialing and re-credentialing processes are integral components of The Health Plan quality management program. The credentialing and re-credentialing processes help to verify that qualified providers, who are capable of meeting the needs of the persons who are seeking and/or receiving services, participate in The Health Plan provider network.

Credentialing and re-credentialing is an ongoing review process to assure the current competence of practitioners by validating the training and competence of individual practitioners in particular specialty areas. This level of review is intended to provide verification that the appropriate training, experience, qualifications, and ongoing competence has been demonstrated by individual practitioners for the services they provide.

The credentialing and re-credentialing requirements differ depending on the provider type. Physicians, nurse practitioners, physician assistants, psychologists and all other health professionals who are registered to bill independently or provide services for which they are licensed to perform must be credentialed prior to providing services to members.

This section applies to providers providing services to persons enrolled in the AHCCCS health system or AHCCCS Health Plan. Provider types subject to credentialing and re-credentialing requirements include, but are not limited to:

Individual Providers

• Physicians (MD)
• Doctor of Osteopathic Medicine (DO)
• Doctor of Podiatric Medicine (DPM)
• Naturopaths (Naturopathic Doctory (ND) or Naturopathic Medical Doctor (NMD)
• Nurse Practitioners (Nurse Practitioners must have certifications that align with their Scope of Practice)
• Physician Assistants
• Certified Registered Nurse Anesthetists
• Certified Nurse Midwives (acting as PCP, including prenatal care/delivering providers)
• Psychologists
• Dentists (DDS or DMD)
• Affiliated Practice Dental Hygienists
• Optometrists
• Occupational Therapists
• Speech and Language Pathologists
• Physical Therapists
• Independent behavioral health professionals who contract directly with the Contractor including:
  • Licensed Clinical Social Worker (LCSW),
  • Licensed Professional Counselor (LPC),
  • Licensed Marriage/Family Therapist (LMFT), and
  • Licensed Independent Substance Abuse Counselor (LISAC)
  • Clinical Nurse Specialist
• Any non-contracted provider that is rendering services and sees 50 or more of the Health Plan’s members per contract year.
• Covering or substitute oral health providers that provide care and services to the Health Plans’s members while providing coverage or acting as a substitute during an absence of the contracted provider. Covering or substitute oral health providers must indicate on the claim form that they are the rendering provider of the care or service.

Organizational Providers:

• Hospitals and units in general hospitals
• Home Health Agencies
• Attendant care agencies
• Habilitation Providers
• Group homes
• Child/Adult developmental homes
• Nursing supported group homes
• Nursing facilities
• Dialysis centers
• Dental and medical schools
• Free standing surgical centers
• Intermediate care facilities
• State or local public health clinics
• Air transportation
• Non-emergency transportation vendor
• Laboratories
• Pharmacies
• Federally Qualified Health Centers
• Community/Rural/Mental Health Clinics (Centers)
• Rescpite homes/providers
• Independent clinics
• Community service agency (CSA)
• Level 1 Sub-Acute Facilities
• Community Service Agency
• Crisis services provider/agency
• Behavioral health residential facility
• Behavioral health outpatient clinic
• Specialized assisted living centers
• Specialized assisted living homes
• Integrated Clinics
• Rural substasnce abuse transitional agency
• Behavioral health therapeutic home
• Respite homes/providers
  • Behavioral health facilities, including but not limited to:
  • Independent clinics
  • FQHCs,
  • Community mental health centers
  • Level 1 Sub-Acute Facilities (IM and non-IMD)
  • Intermdiate Care Facility/Individuals with Intellectual Disabilities
  • Level 1 Residential Treatment Center (IMD)
  • Level 1 Residential Treatment Center Non-Secure (non-IMD)
  • Level 1 Residential Treatment Center Non-Secure (IMD)
  • Community mental health centers
  • Crisis services provider/agency
  • Behavioral health residential facility
  • Behavioral health outpatient clinic
  • Specialized assisted living centers
  • Specialized assisted living homes
  • Integrated Clinics
  • Rural substasnce abuse transitional agency
  • Behavioral health therapeutic home
  • Respite homes/providers
  • Specialized assisted living centers
  • Specialized assisted living homes

If The Health Plan delegates any of the credentialing/re-credentialing or selection of provider responsibilities, The Health Plan is required retain the right to approve, suspend, or terminate any providers selected and may revoke the delegated function if the delegated performance is inadequate.

Providers wishing to join The Health Plan Network must complete the Potential Provider Application for review and approval prior to applying for credentialing, located here: https://www.azcompletehealth.com/providers/become-a-provider.html. Initial applications will not start the formal credentialing process unless approved by The Health Plan’s Potential Provider Committee.

The initial credentialing process includes verification of information submitted on the credentialing application and a site visit (if applicable), and is completed before the effective date of the initial contract. An application must be complete, signed, and dated. Credentials with expiration dates must be valid at the time of approval. Initial credentialing is completed within 60 calendar days from receipt of a complete application, accompanied by the designated documents, to render a decision for approval or denial.

The Health Plan is required to utilize the Arizona Association of Health Plan’s (AzAHP) Credentialing Verification Organization (CVO) as part of the credentialing process.  As part of this process, it is required that all individual applicants be enrolled in the Council for Affordable Quality Healthcare (CAQH) and maintain a current CAQH application and attestation in order to be credentialed. Providers must also utilize the AzAHP credentialing data forms. The Health Plan’s Credentialing Department reserves the right to specify exceptions to this process to meet network needs.

For organizational provider types not requiring CAQH registration, an AzAHP credentialing application and data form must be completed in its entirety and submitted along with all required documentation. This form can be found on The Health Plan website, here: https://www.azcompletehealth.com/providers/become-a-provider/credentialing-forms.html. Credentialing applications should be submitted as indicated on the AzAHP credentialing forms.

Any provider that has changed its NPI or provider type or Organizational Providers who have moved locations, must submit new credentialing applications. Providers that have failed to re-credential timely, must also complete the initial credentialing process.

The initial credentialing process may include verification of the following:

• Application Completeness;
• License;
• Minimum five year work history or total work history if less than five years;
• Insurance Coverage;
• Drug Enforcement Administration (DEA) Certificate (if applicable);
• Controlled Substance Certificate (if applicable);
• Board Certification (if applicable);
• Education;
• Sanction Information;
• Malpractice History;
• Site Survey;
• CLIA License (if applicable);
• Pharmacy License (if applicable);
• W-9

Hospitals and other licensed health care facilities are included in this process. Prior to contracting with an organizational provider, the Health Plan verifies that organizations have been reviewed and approved by a recognized accrediting body or meet the Health Plan’s standards for participation and are in good standing with state and federal agencies. Organizational providers include, at a minimum, hospitals, outpatient treatment centers, home health agencies, skilled nursing facilities, nursing homes, crisis services providers, freestanding surgical centers and behavioral health facilities providing mental health or substance use disorder services in an inpatient, residential or ambulatory care setting. Once approved to join the Health Plan’s network, the AzAHP credentialing data and application forms must be completed, along with all required documents. This form and detailed submission information can be found on our Credentialing Forms page. Credentialing applications should be submitted as indicated on the AzAHP credentialing forms.

The initial credentialing process may include verification the following:

• Application Completeness;
• License;
• Accreditation of JCAHO/CARF/COA/or AOA (If applicable);
• Site Survey not more than 3 years old;
• Insurance Coverage;
• CLIA License (If applicable);
• Pharmacy License (if applicable);
• W-9.

For organizational providers that are not accredited and do not have a current Center for Medicare and Medicaid Services (CMS) certificate, or do not have a state license that denotes a recent Site Survey, an onsite inspection will be done by Provider Relations or a Network Specialist determine the scope of services available at the facility, physical plant safety, review of the quality improvement program for adequate mechanisms to credential practitioners delivering care in the facility, identify and manage situations involving risk, and assess the medical record keeping practices.

Community Service Agencies are subject to additional requirements, for more information see the AHCCCS AMPM Chapter 900, Policy 950.

In an effort to comply with applicable federal and state laws and regulations, all participating providers in The Health Plan’s network must comply with the following standards when hiring a non-participating provider to provide services to The Health Plan members.

The Health Plan’s participating providers must be able to demonstrate that each non-participating provider has supporting documentation that includes:

• Current, unencumbered state medical license;
• Valid, unencumbered Drug Enforcement Agency (DEA) certificate, as applicable or Chemical Dependency Services (CDS) certificate, as applicable;
• Evidence of adequate education and training for the services the practitioner is contracting to provide;
• Malpractice insurance coverage through their own practice or through the hiring of The Health Plan’s participating provider;
• Absent of any sanctions that would not allow them to see a Medicare member.

Additionally, the practitioner must be absent from:

• The Medicare Opt Out report if treating Medicare members The Office of the Inspector General’s (OIG) sanctions List of Individuals and Entities (LEIE) if treating Medicaid and Medicare members;
• The System for Award Management’s Exclusions Extract Data Package (EEDP) if treating Medicare members;
• The Federal Employee Health Benefits Program Debarment Report if treating federal members.

The Health Plan investigates adverse activities indicated in a practitioner’s or provider’s initial credentialing or recredentialing application materials or as identified between credentialing cycles. The Health Plan may also be made aware of such activities through primary source verification utilized during the credentialing process or by state and federal regulatory agencies. The Health Plan may require a practitioner or provider to supply additional information regarding any such adverse activities.

Examples of such activities include, but are not limited to:

• State or local disciplinary action by a regulatory agency or licensing board;
• Current or past chemical dependency or substance abuse disorder;
• Health care fraud or abuse;
• Member complaints;
• Substantiated quality of care concerns Impaired health;
• Criminal history;
• Office of Inspector General (OIG) Medicare/ Medicaid sanctions;
• Federal Employees Health Benefits Program (FEHBP) debarment;
• Substantiated media events;
• Trended data;
• At The Health Plan’s request, a practitioner or provider must assist in investigating any professional liability claims, lawsuits, arbitrations, settlements, or judgments that have occurred within prescribed time frames.

A request to add new facilities or providers to an existing Provider Participation Agreement (PPA) requires completion of the AzAHP Practitioner Data Form for physicians or AzAHP Organization Facility Application. These forms are located on the Arizona Complete Health website. New physicians are not permitted to treat the Health Plan’s members until all credentialing requirements have been met and the physician has been formally added to the PPA.

Note: Providers must include their National Provider Identifier (NPI) on the Provider Participation Request form they submit to the Health Plan.

Providers participating in The Health Plan must include the Arizona Health Care Cost Containment System (AHCCCS) identification number and NPI. Any subsequent changes to either the AHCCCS identification (ID) number or NPI require the submission of a request for processing.  Instructions for these requests are located on the following credentialing forms page.

Provider data changes include:

• Name changes;
• Tax ID numbers, Group NPI’s, or changes or additions of AHCCCS ID numbers;
• Primary address and billing address changes;
• Addition or deletion of locations;
• Provider termination notifications;
• Specialty or sub-specialty changes.

When changing a tax ID number, include a new W-9 and the effective date. Participating providers may be held responsible for Internal Revenue Service fines imposed by The Health Plan associated with incorrect tax IDs if the provider fails to notify The Health Plan in writing prior to the change. The Health Plan is unable to change tax IDs retroactively.

Changes must be submitted in writing to The Health Plan Network Operations Department at least 30 days prior to the change or as soon as reasonably possible.

The Health Plan must approve any new or modified subcontracts prior to the effective date.

5.7.1 Provider Online Data Verification

Physicians, hospitals, ancillary providers, and medical groups or IPAs are required to provide advance notification to The Health Plan or their medical groups or IPAs with changes to their provider data information. On a monthly basis, providers should validate that their information is reflected correctly on the provider website under Find a Provider.

5.7.2 Provider data Information

Providers’ data information should include the following:

• Name;
• Address;
• telephone number;
• fax number;
• office hours;
• languages other than English spoken by the physician handicap accessibility status for parking (P), exterior building (EB), interior building (IB), restroom (R), exam room (ER), and exam table/scale (T) - if accessibility is not yes to all, then indicate no.

5.7.3 Notification and Maintenance Requirements

According to the terms of the Provider Participation Agreement (PPA), participating providers are required to provide a minimum of 30 days advance notice of any changes to their  information. If the change pertains to the status of accepting new patients, the provider must notify The Health Plan 45 days prior to the decision to no longer accept Covered Persons with respect to a particular product.

Providers directly contracting with The Health Plan must notify The Health Plan and AHCCCS of changes (address, contact information, other demographic information, etc). Providers are able to inform The Health Plan of changes by emailing AZProviderData@AZCompleteHealth.com. Providers are able to notify AHCCCS by completing an AHCCCS Provider Address Update Form located on AHCCCS’ website.  

Providers contracting through a medical group or IPA must notify the medical group or IPA directly of changes, and the medical group or IPA notifies the Health Plan and AHCCCS. Medical groups or IPAs must have policies in place that establish and implement processes to collect, maintain and submit their provider data changes to the Health Plan within 30 days. 

5.7.4 AHCCCS Minimum Subcontract Provisions

Providers refer to your Provider Participation Agreement for the latest information on AHCCCS Minimum Subcontract provisions. Any subcontractors must also comply with AHCCCS minimum subcontract provisions. To view the full provision please refer to: https://www.azahcccs.gov/PlansProviders/HealthPlans/minimumsubcontractprovisions.html

5.7.5 Terminations

Participating providers terminating a physician, clinician, or other entity from an existing Provider Participation Agreement (PPA) must submit the following information:

• Physician’s full name;
• Physician’s NPI;
• Specialty type (or entity type if facility or ancillary);
• License number;
• Tax ID;
• Group NPI;
• Practice location address;
• Effective date of the change;
• Covering physician;
• Contact name, address and telephone number.

This information must be submitted in writing to The Health Plan Network Operations Department at least 60 days prior to the termination. Upon termination, The Health Plan may invoke a 12-month waiting period before the provider may re-apply for a contract; however, the termination clause varies based on the PPA.

The Health Plan must be notified of participating providers who terminate a subcontract. This information must be submitted in writing to The Health Plan Network Operations Department at least 60 days prior to the termination.

Occasionally, it is in the interest of members to allow practitioners availability in the network prior to completion of the entire initial credentialing process. Provisional credentialing is intended to ensure member service delivery and provider availability in medically underserved areas, based on The Health Plan’s network sufficiency.

Practitioner and provider types that may qualify for provisional credentialing include, but not limited to:

• Federally Qualified Health Centers (FQHC)
• FQHC Look-A-Like organizations
• Rural Health Clinic (RHC)
• Hospital employed physicians (when appropriate)
• Providers needed in medically underserved areas, whether rural or urban
• Providers joining an existing and contracted oral health provider group
• Covering or substitute providers providing services during a provider absence.
• Providers eligible under the Substance Abuse and Mental Health Services Administration (SAMHSA) Certified Opioid Treatment Programs (OTPs) per 42 CFR 8.11. 
• Providers as directed by AHCCCS during federal and/or state-declared emergencies where delivery systems are, or have the potential to be, disrupted

Provisional credentialing is completed within 14 calendar days from receipt of a complete application accompanied by the designated documents to render a decision regarding temporary or provisional credentialing. Practitioners applying to the network for the first time are eligible for provisional credentialing. A practitioner may only be provisionally credentialed once, and practitioners may not be held in a provisional credentialing status for more than 60 calendar days. Providers that are in a provisional status, that do not clear the Initial Credentialing Requirements will be terminated.

The recredentialing of providers is completed every 36 months. As part of the recredentialing process, providers are notified 180 days in advance of the expiration of their credentials. The Credentialing Department will mail, fax or email notifications to the providers at least three times within the notification cycle. In order to avoid a lapse in network participation status, the recredentialing application and required documents must be valid at the time of approval.  Any provider that fails to recredential timely, will have to undergo the initial credentialing process. Providers that fail to recredential cannot request provisional credentialing status. The provider will be required to complete and submit applicable credentialing applications, data forms and all required supplemental documentation. The forms and detailed submission instructions can be found here: https://www.azcompletehealth.com/providers/become-a-provider/credentialing-forms.html.

The Health Plan is required to utilize the Arizona Association of Health Plan’s (AzAHP) Credentialing Verification Organization (CVO) as part of the recredentialing process.  As part of this process, it is required that all individual applicants be enrolled in the Council for Affordable Quality Healthcare (CAQH) and maintain a current CAQH application and attestation in order to be credentialed. Providers must also utilize the AzAHP credentialing data forms.  The Health Plan’s The Health Plan Credentialing Department reserves the right to specify exceptions to this process to meet network needs.

For organizational provider types not requiring CAQH registration, an AzAHP credentialing application and data form must be completed in its entirety and submitted along with all required documentation. This form can be found on The Health Plan’s website, here: https://www.azcompletehealth.com/providers/become-a-provider/credentialing-forms.html

The recredentialing process includes the verification of all the elements include during initial credentialing, with the addition of member concern/grievances, utilization management, performance improvement, results of medical record audits, and quality of care concerns.

Completed credentialing and recredentialing requests are presented to the Credentialing Committee Chair, or designee, for review prior to presentation at Credentialing Committee. Initial credentialing files that were not considered adverse, may receive approval during the review. Recredential files and credentialing files that exceed the credentialing standards (adverse) must be taken to the Credentialing Committee for review and determination. It is the responsibility of the Credentialing Committee to review the issues/concerns and qualifications of each applicant presented and make approval or denial determinations.

All applicants receive notice of their status in writing within 14 calendar days of the Credentialing Committee decision.

When there are extenuating circumstances that preclude the practitioner from meeting minimum participation criteria, but do not preclude the practitioner from providing quality care and service for The Health Plan’s Members, the Medical Director/ Credentialing Committee Chair /Credentialing Committee may decide to extend an offer of participation. If such a need exists, each criterion for selection shall be examined on an individual basis taking into account the following:

• Malpractice claims history;
• If there is a history of drug or alcohol abuse, the applicant must be involved in a credible program to correct impairment with concurrent and present monitoring by the medical society or state board. There should be no evidence of recidivism;
• Previous sanction activity: the nature of the sanction and remedy; and
• Office site visit: a plan to remedy any deficiencies with provisional approval until the remedy is achieved.

If the Credentialing Committee requires additional information prior to making a determination, the application will be pended in order to obtain additional information or clarification for the Credentialing Committee. Once the requested information has been obtained, the file will be presented to the Credentialing Committee at a future Credentialing Committee meeting.

The Credentialing Committee will review and grant exceptions on an individual basis, depending on the outcome of the review.

The Health Plan or its designee shall maintain fair credentialing and re-credentialing processes which:

• Do not discriminate against a provider solely on the basis of the professional’s license or certification; or due to the fact that the provider serves high-risk populations and/or specializes in the treatment of costly conditions;
• Afford the provider the right to review information gathered related to their credentialing application and to correct erroneous information submitted by another party. The organization is not required to reveal the source of information if the information is not obtained to meet organization credentialing verification requirements or if disclosure is prohibited by law;
• Notify the provider when the information obtained through the primary source verification process varies substantially from what the provider provided;
• Verify credentialing/re-credentialing information is kept confidential; and
• State that practitioners have a right to be informed of the status of their application upon request and must describe the process for responding to such request, including information that the organization may share with practitioners with the exception that this does not require the organization to allow a practitioner to review references, recommendations, or other peer-review protected information.

The Health Plan is required have procedures for reporting to appropriate authorities, including the Arizona Health Care Cost Containment System (AHCCCS), the provider’s regulatory board or agency, Adult Protective Services (APS), Department of Child Safety (DCS), Office of the Attorney General (OAG), any known serious issues and/or serious quality deficiencies that could result in a provider’s suspension or termination from The Health Plan’s network. If the issue is determined to have criminal implications, a law enforcement agency must also be notified. The Health Plan is required to:

• Maintain documentation of implementation of the procedure, as appropriate;
• Have a reconsideration process for instances in which The Health Plan The Health Plan chooses to alter the provider’s contract based on issues of quality of care and/or service; and
• Inform the provider of the reconsideration process.

Other standards related to the credentialing process include the following:

• The credentialing process must be in compliance with federal requirements that prohibit employment or contracts with providers excluded from participation under either Medicare or Medicaid:
  • Documentation must show that the following sites have been queried. Any provider that is found to be on any of the lists below may be terminated without the right to appeal:
    • Health and Human Services-Office of Inspector General (HHS-OIG) List of Excluded Individuals/Entities (LEIE); and
    • General Services Administration (GSA) Excluded Parties List System (EPLS). Use Chrome when accessing this website.
• Mechanisms must be put in place to verify that licensed providers renew licenses or certifications required by the appropriate licensing/certifying entity and continuously practice under a current and valid license/certification; and
• Health care providers who are part of The Health Plan network are subject to an initial site visit as part of the initial credentialing process or in the case of adverse findings on the States Site Survey or on the CMS Site Survey Report.

The Health Plan’s Medical Director or Credentialing Committee may decide not to extend participation status to an applicant. The Credentialing Committee Chair or designee will notify the practitioner of the Credentialing Committee denial decision within 10 calendar days of the Credentialing Committee’s decision.

The letter of denial shall include information on the practitioner’s right to review information obtained by The Health Plan to evaluate the practitioner’s credentialing and/or re-credentialing application, and right to request reconsideration and/or correct any erroneous information submitted by another party in the event the practitioner believes any of the information is erroneous or if any documents gathered during the primary source verification process differ from those submitted by the practitioner. A copy of the letter will be retained in the practitioner’s closed file and maintained in the monthly Credentialing Committee folders for future reference.

Information obtained from any outside primary source will be released to a practitioner only if the practitioner has submitted a written and signed request to The Health Plan’s Credentialing Department.

New applicants who are declined participation for reasons such as quality of care, their credentials have exceeded threshold limits or liability claims issues have the right to request a reconsideration of the decision in writing within thirty 30 calendar days of the formal notice of denial.  All written requests will need to include additional supporting documentation in favor of the applicant’s reconsideration for network participation.  Reconsiderations will be reviewed by the Chief Medical Officer, Medical Director Designee or at the next regularly scheduled Committee meeting, but in no case later than 60 calendar days from the receipt of the additional documentation.  Applicants will be notified within 10 calendar days of the committee decision.  The provider does not have the any further recourse if the decision is to uphold the initial decision.

Should any information gathered as part of the primary source verification process differ from that submitted by the practitioner on the application, the practitioner must provide a written explanation detailing the error or the difference in information within 30 calendar days of receipt of the committee decision.

Providers who are denied initial participation may reapply for admission into The Health Plan’s network no earlier than one year from the Credentialing Committee final decision date.

Recredentialing Applicants: Current Practitioners whose participation is suspended, reduced, or terminated, shall have the right to request reconsideration of the decision in writing within 30 calendar days of receipt of the formal termination notice.  All written requests for reconsideration will need to include additional supporting documentation in favor of the applicant’s request for continued network participation. The reconsideration review will be scheduled no later than 60 days after the receipt of the request.  The final recommendation will be based upon the practitioner’s submitted credentials, the credentialing committee’s recommendations and supporting documentation submitted by the provider. The reconsideration determination will be by an affirmative vote of the majority of the members of the panel.  The provider does not have the any further recourse if the decision is to uphold the recredentialing denial.

Terminations that cannot be reconsidered: Per AHCCCS AMPM Chapter 900-950 - Credentialing And Recredentialing Processes, any provider that is found to be on the Health and Human Services Office of Inspector General (HHS-OIG) list of Excluded Individual/Entities (LEIE) or the General Services Administration Excluded Parties List Systems (EPLS) will be terminated without the right to appeal.

The Health Plan’s Credentialing Department monitors on a monthly basis:

• Practitioner Medicare/Medicaid sanctions;
• Limitations or sanctions on State licensure;
• The Compliance Department submitted report of Office of Inspector General (OIG) and Excluded Parties List System (EPLS) checks;
• Items eligible for expiration.

Reports are provided to the Credentialing Committee. The Chief Medical Officer (CMO) or designee working with the Credentialing Committee will initiate appropriate corrective action for providers when occurrences of poor quality are identified. The CMO, designee or Credentialing Committee reviews sanctions during regularly scheduled meetings or via an Ad Hoc emergency meeting. For records that have been submitted to the Credentialing Committee, the Committee’s members will be asked for their professional feedback and be given an opportunity to vote on whether or not the provider should be allowed continuation in The Health Plan’s Network or be placed on administrative review or corrective action.

Providers will be immediately terminated if they are found to be excluded from the Medicaid/Medicare programs via the OIG or EPLS checks conducted. For reconsideration, a release from the reporting agency must be submitted. Corrective Action Plans (CAPs) in progress are not considered a release from the reporting agency.

The Health Plan has procedures for reporting (in writing) to appropriate authorities (AHCCCS, the provider’s regulatory board or agency, Office of the Attorney General, etc.) any known serious issues and/or quality deficiencies. If the issue/quality deficiency results in a provider’s suspension or termination from The Health Plan’s Network, it must be reported. If the issue is determined to have criminal implications, a law enforcement agency must also be notified.

• The Health Plan is required maintain documentation of implementation of the procedure, as appropriate;
• The Health Plan is required have an appeal process for instances in which The Health Plan chooses to alter the provider’s contract based on issues of quality of care and/or service; and
• The Health Plan is required to inform the provider of the reconsideration process.

In accordance with AHCCCS ACOM Policy 406 - Member Handbook And Provider Directory and AHCCCS ACOM Policy 416 - Provider Information, the Health Plan maintains a web-based provider directory that includes the following provider location accessibility information, obtained from the AzAHP forms submitted by the provider:

• Non-English language, if any, spoken or signed by a health care provider or other medical professional as well as non-English language spoken or signed by a qualified medical interpreter, if any, on the provider’s staff.
• Physical and Equipment Accessibility Information that shows if a participating provider/entity has basic or limited access in, at a minimum, the following areas:
• American Sign Language - Signage with Braille and raised tactile text characters at office, elevator, stairwells, and restroom doors. Rooms that are not likely to change function (like a restroom, kitchen, elevators, etc.) should be identified by name. Other rooms that may change function can be identified by a numbers or letters.
• Exam Room, the entrance to the exam room is accessible with a clear path. The doors open wide enough to accommodate a wheelchair/scooter to turn around.
• There is an accessible ramp to the building. Curb ramps and other ramps to the building are wide enough for a wheelchair/scooter. Handrails are provided on both sides of the ramp. Doors are wide enough to allow entrance for a wheelchair/scooter and the doors have handles that are easily opened
• Doors are wide enough for a wheelchair/scooter and have handles that are easily opened. There are interior ramps available, and the ramps have handrails. If an elevator is present, it must be available for use by the public and patients. The elevator has easy-to-hear sounds and Braille buttons within reach. The elevator is large enough for a wheelchair/scooter to turn around. If a chair lift is present, it can be utilized without help
• CMS Medical Equipment Access. An accessible examination room has features that make it possible for patients with mobility disabilities, including those who use wheelchairs, to receive appropriate medical care. These features allow the patient to enter the examination room, move around in the room, and utilize the accessible equipment provided. The features that make this possible are:
  • an accessible route to and through the room;
  • an entry door with adequate clear width, maneuvering clearance, and accessible hardware;
  • appropriate models and placement of accessible examination equipment (including an adjustable height accessible exam table that lowers for transfers) and adequate clear floor space inside the room for side transfers and use of lift equipment.
• Parking spaces, including van-accessible space(s), are accessible. Pathways have curb ramps between the parking lot, office and at drop-off locations.
• Patient Areas Members can get to and use all common areas and equipment with or without help.
• Patient Diagnostic and Treatment Use Patients are able to access and use testing and treatment areas, and equipment.
• The restroom is accessible, has doors wide enough to accommodate a wheelchair/scooter and are easy to open. The restroom is large enough for a wheelchair/scooter to turn around and close the door. The restroom has grab rails which allows a transfer from the wheelchair to the toilet. Toilet paper is easy to reach. The sink is accessible, and the faucets and soap are easy to reach and us
• Exam Table/Scale. There is a height-adjustable exam table. There is enough room next to the exam table for a wheelchair/scooter user to approach, park and transfer or be assisted onto the exam table. There is a weight scale with a platform that can accommodate a wheelchair/scooter and the patient.
• A statement informing enrollees that they are entitled to language assistance services at no cost, including information on how to obtain oral interpretation and written translation services.
• A statement informing enrollees that they are entitled to full and equal access to covered services, including enrollees with disabilities as required under the Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
• Access to Web-based directory must be available to the public without restrictions or limitations and be 508 compliant.

Members with disability access needs may contact the Health Plan toll-free Member Services number at 1-888-788-4408 (TTY/TDD Hearing Impaired: 711) to request:

• An accommodation from the Health Plan; or assistance requesting an accommodation from an Arizona Complete Health provider, vendor, affiliate, and/or delegate.
• Health Plan staff assists members with scheduling appointments or other health plan activities shall ask the member if they “need any assistance with walking, seeing, reading, hearing, communicating, speaking, filling out forms, getting on and off a table, or any other assistance.”
• Health Plan staff will record in all data systems, in a consistent and prominent place, any member disability access needs, accommodation requests, and actions taken in response to requests. This information shall be routinely updated during each contact.
• The entire interactive process to respond and implement the member’s request shall be completed within (30) calendar days, or sooner if necessary to provide an urgent accommodation (e.g., for an acute situation).